Growing public health nursing: Public Health Nursing Education Framework discussion document

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Growing public health nursing:

Public Health Nursing Education Framework

discussion document

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Funded by: The Ministry of Health

Project managed and written by the Public Health Nursing Education Framework Working Group, the Public Health Association of New Zealand and Head Strategic Limited

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Contents

Part 1: Context

. . . .

4

What is the purpose of this discussion document and who is it for? . . . 5

How can you provide feedback on this document? . . . 7

Who are public health nurses and what do they do? . . . 8

Why is a Public Health Nursing Education Framework needed? . . . 10

What could be included in the Public Health Nursing Education Framework? . . . 11

Workforce development challenges and opportunities for public health nursing . . . 11

What is the current public health nursing education pathway? . . . 12

Part 2: Isues and recommendations

. . . .

14

Step 1 – Prior to starting a Bachelor of Nursing degree . . . 15

Step 2 – Bachelor of Nursing . . . 16

Step 3 – Nursing Entry to Practice Programme . . . 18

Step 4 – First and subsequent PHN positions (after NETP) for registered nurses (with or without other nursing experience) . . . 20

Step 5 – Advanced public health nursing roles . . . 22

Step 6 – Nurse practitioner – PHN . . . 25

Step 7 – Nurse academic – PHN . . . 26

Where to from here? . . . 27

Appendices

. . . .

28

Appendix 1: Te Uru Kahikatea objectives relevant to public health nursing . . . 29

Appendix 2: Individuals involved in this project . . . 30

Appendix 3: Public health nursing demographics . . . 31

Appendix 4: History of public health nursing by Elizabeth Farrell, 2013 . . . 32

Appendix 5: Short-, medium- and long-term visions for PHN workforce development . . . 35

Appendix 6: Generic Public Health Competencies . . . 36

Appendix 7: New Zealand Certificate in Public Health . . . 37

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What is the purpose of this discussion

document and who is it for?

Public health nurses play an important role in supporting individuals, families, communities and populations to meet their own health and wellbeing needs. Future-proofing the public health nursing workforce by ensuring its competence in a changing society is essential to meet the population and personal health needs of New Zealand communities.

At present, there is no national framework for public health nurses’ professional development. This discussion document is part of a nurse-led project to set a way forward.

The purpose of this discussion document is to: • summarise the current educational

framework for public health nurses (PHNs) • outline the key issues that PHNs experience

on their educational journey • ask for feedback on the proposed

recommendations which will inform the development of the Public Health Nursing Education Framework.

A framework could support the development of all registered nurses who work to change determinants of health such as infectious diseases or child protection. While it focuses on public health nurses, the framework also includes nurses who work in primary health care.

Public health nursing is not about the role of a registered nurse, but about the essence of his/ her practice. Many primary health care nurses take a population health approach in their daily work, and play an important part in addressing the determinants of health.

Who is this discussion document

for?

Public health nursing key stakeholders – nurses, nurse leaders and managers – are the main audience for this discussion document. However, we would also like feedback and comment from anyone interested in the development of public health nursing. This might include professional bodies, nursing and

public health education providers, nursing school representatives, District Health Boards, public health doctors, community workers who work with public health nurses, and government agencies concerned with health service development and with population health. The Education Framework to come out of this discussion document will allow PHNs (and other registered nurses who undertake public health and population health work) to access education that develops both their public health and population health nursing knowledge and skills.

The framework aims to be flexible and to have multiple entry and exit points.

How did this discussion document

come about?

The need for this project was identified by a group of experienced public health nurses. It was strongly supported as a priority by a 2012 national meeting of representatives from public health disciplinary groups.

The Ministry of Health has funded this project and provided advice and support. The project connects to Te Uru Kahikatea: The Public Health Workforce Development Plan 2007-2016,1_{which includes a}

number of goals and actions relevant to public health nursing (see Appendix 1).

The major outputs for this project will be: 1. consultation on this discussion document

with a range of stakeholders

2. a national Education Framework for public health nurses and other registered nurses doing public health and population health work

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3. an implementation plan to identify next steps, roles and responsibilities and

timelines to bring the Education Framework to fruition.

How the project is being managed

and supported

This project is led by the Public Health Nursing Education Framework Working Group, a group of experienced public health nurses, nurse leaders and nurse educators. The Public Health Association is providing project and administrative support to the working group.

The working group is supported by an advisory group of people with expertise in public health nursing, Māori health, Pacific health, public health workforce development, project management, and professional nursing practice.

The advisory group includes members from Health Workforce New Zealand, Nursing Council of New

Public health/population health

Public health has been described as “the science and art of promoting health, preventing disease and prolonging life through the organised efforts of society.” Public health work focuses on improving the overall health of populations, such as children, through interventions such as immunisation, health screening checks, or safer housing.

Population health focuses on the health outcomes or status of population such as groups, families

and communities. A population health approach takes account of all the influences on health (the determinants of health) and how they can be tackled to reduce inequalities and improve the overall health of the population.

Zealand, District Health Boards’ Directors of Nursing, the New Zealand Nurses Organisation and the Public Health Association (see Appendix 2). The Ministry of Health’s Chief Nurse Business Unit and the Public Service Association have also expressed support for this project.

The working group would also like to acknowledge the very experienced and highly skilled public health nurses who have spent many years

committed to making a significant difference in the lives of many in their communities.

Whether or not they choose not to travel the journey along the Education Framework, they can play a vital role in supporting the next generation of PHNs to pursue continuing education.

Appreciation is extended to this group in anticipation of the encouragement they offer to members of the nursing workforce following in their footsteps.

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There are several ways you can provide feedback on this document and its recommendations.

Hard copy

You can provide comment on the hard copy, and mail it to us at:

Public Health Association of New Zealand PO Box 11-243

Wellington 6142

By email

You can email comments to Leona Head at leona@pha.org.nz.

Online discussion forum

We invite you to share in the online discussion about the issues at the user-friendly Loomio discussion space. You’ll find links to the online discussion at www.pha.org.nz.

How can you provide feedback on this

document?

Currently, there is no continuous or coherent professional and educational development pathway for public health nursing in New Zealand.

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Case study 1

While visiting her assigned school, Rachel was told by the school that Josef, a nine-year-old Tongan boy with whom Rachel had been working with for a number of months, had not been at school for the past three days. Rachel decided she would home visit on her way back to the office.

On arriving at Josef’s house she could see preschool children playing on the doorstep and a dog running around the yard. Rachel asked for the dog to be tied up and after this was done she spoke with Josef’s mum, Anna. Josef had been off school unwell.

When she was talking to Josef he told Rachel he had a ‘wicked’ sore throat. Rachel immediately arranged to take a throat swab to screen for Group A Streptococcus – the cause of rheumatic fever. Rachel also assessed the health status of other family members and provided education regarding sore throats and rheumatic fever. Anna told Rachel that her nephew had rheumatic fever and was on injections. Rachel also assessed and discussed the early childhood education needs of the preschoolers with Anna along with their immunisation status.

Who are public health nurses and what do

they do?

Public health nurses (PHNs) are registered nurses who use their nursing expertise, alongside their wider knowledge of communities, to promote health and wellbeing.2

They play an integral role in delivering public health services in New Zealand. PHNs work in many settings, such as schools, homes and community health services. They operate across many sectors – for instance some public health nurses are based at Work and Income offices. PHNs work with complex population and personal health issues, such as those described in Case Study 1.

PHNs have a range of competencies that are important to the health sector in Aotearoa New Zealand. As a relatively small workforce – there are only 700-800 public health nurses nationwide3 – their core work is often not visible to the

information about the public health nursing workforce from 2010.

To gain insight into the unique contribution PHNs have made to improve the health of communities both locally and internationally, you can read about the historical development of public health nursing from the late nineteenth century to the present day in Appendix 4.

Most PHNs are involved in co-ordination and case management between families/whānau and

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Case study 2

Margaret works in a community health centre providing a range of services to support health and wellbeing among community members. Because the health centre is located in school grounds, Margaret is able to work closely with the local school and their families as well as with other community members.

Margaret provides the following types of services for community members and their families: general health checks, diabetes support, hearing checks, B4 school checks, quit smoking support, cervical screening smears, housing, income and welfare support, counselling, access to dietary advice, respiratory guidance, and/or referral to any other health or social service as required. A common scenario is a child identified by the school who is not managing their asthma.

Margaret is able to visit the home, provide education and support for the family and child regarding asthma, and support the school through education and information for teachers about children with asthma. As part of the home visit, Margaret is able to assess any housing, social or financial needs with the family and arrange for appropriate support.

• disease prevention • refugee health • child protection

• communicable disease control, such as primary prevention of rheumatic fever • working with teachers to promote health

programmes in schools

• facilitating multidisciplinary ‘strengthening families’ meetings

• developing one-stop-shop health services for young people

• playing a major part in implementing school-based immunisation programmes

• advocating for healthy home environments with families and communities.

Within this work, PHNs have an important role establishing partnerships and communication strategies with Primary Health Organisations to improve health outcomes for communities.

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Why is a Public Health Nursing Education

Framework needed?

In response to changing needs – and in some cases due to reduced funding and changes in government strategies – public health nursing and public health nursing roles have changed significant over the last 20 years.

Accessing opportunities and funding for

professional development in public health nursing has become increasingly challenging.

Currently, there is no continuous professional and educational development pathway for public health nursing in New Zealand. Individually, PHNs may choose to undertake qualifications after completing their undergraduate nursing degree, but those qualifications are not specific to public health nursing, and may not even be related to public/population health.

There is some regional or organisational public health nursing education; however, national consistency is an issue, and what is available is not linked to any professional development pathway. High quality, consistent public health nursing services in New Zealand demand national public health nursing education. This will increase the opportunity for nurses to develop population health knowledge and skills, and could be available to other RNs who work in the community.

The Education Framework is intended as a conceptual framework that organises the hierarchy of qualifications relevant to public health nursing in New Zealand. It will frame the education pathway from beginner to expert, with multiple entry and exit points.

This pathway aims to help those involved in public health nursing to advance towards the top of their scope of practise, using advanced competencies and clinical skills. It may also allow PHNs to gain recognition as a highly skilled nursing workforce, and could help attract registered nurses into public health nursing.

Over time the Education Framework could, for example:

• increase the number of highly qualified PHNs who can provide evidence-based public health nursing services to vulnerable communities

• lead to better population health outcomes, as PHNs increase their clinical expertise and better understand the effect social determinants of health have on inequalities, chronic health needs and unmet community health needs

• lead to health cost savings through PHNs initiating preventative measures and early interventions for vulnerable populations. This could avoid costly hospital admissions and long-term health problems: for example, the earlier detection and treatment of skin infections, oral health issues and hearing loss • enable nurses to advocate for better access

to services for Māori, Pacific, and other populations with particular needs

• improve collaboration with multidisciplinary teams and build coalitions with a range of services

• increase the number of PHNs who can successfully lead the management of complex health issues influenced by poor housing, inadequate social support and poverty.

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What could be included in the Public Health

Nursing Education Framework?

The Education Framework could:

1. set a direction for the development of the public health nursing (see Appendix 5) 2. align professional development (PDRP),

registration pathways and education pathways

3. set out a pathway for the stages of

qualification, and enable career progression 4. create a platform for a public health

competencies framework

5. provide a platform for positive change.

Workforce development challenges and

opportunities for public health nursing

Current challenges

• Expectations on the primary care sector to reach vulnerable communities have not been fully realised, and may require a skill set that is not widely available.

• Other areas of the health sector have been given greater priority than public health. • Structural changes in the health sector may

have marginalised the relatively small public health nursing workforce in some areas. • While many younger nurses are coming to

the PHN workforce, the workforce is still an ageing one.

• There is very little information available about New Zealand’s public health nursing workforce to guide workforce development planning.

• Due to financial constraints, employers are often unable to arrange release time for study and provide backfill arrangements. • There is little or no financial recognition for

gaining additional qualifications.

• There is a perception that new graduate nurses lack practical experience, which can inhibit organisations from employing new graduate nurses and PHNs.

• Health Workforce New Zealand (HWNZ) does not currently fund non-clinical graduate nursing courses, creating a barrier to

nurses wanting to work towards the Nurse Practitioner level.

Opportunities

• There is strong interest among public health nurses in taking a greater role in improving health gains in both personal and population health.

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through the current focus on emergency preparedness and response.

• The Public Health Generic Competencies (see Appendix 6) provide a strong foundation for public health knowledge and skills. • There is growing recognition of the need

to fund non-clinical post-graduate nursing qualifications, and interest in expanding the criteria for HWNZ funding to include, for example, post-graduate Public Health Diploma and Masters’ degree programmes. • Distance learning is making study more

accessible.

• There are well-developed communication and consultation mechanisms such as the PHA conference, NZ College of Primary Health Care Nurses’ conference, the

PHN leaders’ national email tree and the regional managers’ meetings, the publichealthworkforce.org.nz website, and the nzno.org.nz website, etc.

• National strategies and policy documents, including Te Uru Kahikatea, NCNZ Scopes of Practice, NZNO Colleges and Sections Nursing Knowledge and Skills Framework (e.g. respiratory, diabetes, primary health nurses), and the DHBNZ Career Framework for the Health Workforce provide direction for public health nursing.

• International frameworks and models of public health nursing practice, such as the USA ‘Minnesota Wheel’ and the UK Career and Development Framework for health visiting and school nurses are influencing practice.

What is the current public health nursing

education pathway?

Table 1 (opposite) summarises the current career steps and education for PHNs. This is the starting point for the Education Framework.

The sections that follow Table 1 review the relevant issues for each of those steps and make recommendations for change.

Please provide your feedback on the issues and recommendations. Your comments will inform the final framework.

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Table 1: Curr

en

t c

ar

eer

, educ

ation and r

egis

tr

ation pa

th

w

ay

s f

or public health nur

ses in Ne

w Z

ealand Aot

ear

oa

4 NETP: Nur sing En tr y t o Pr actice Pr ogr amme – pr ovides gr adua te r egis ter ed nur

ses with support and de

velopmen

t during their fir

st y ear of pr actice. PDRP: Pr of essional De velopmen t R ec ognition Pr ogr amme – adv ances pr of essional de velopmen t in nur

sing and supports nur

ses t o demons tr at e c ompe tency t o the NCNZ St ep Car eer Pr ogr ession Educ ation P ath w ay Na

tional Health Car

eer s Fr ame w ork Regis tr ation Pa th w ay 5 PDRP 1 Various op tions Sec ondar y educ ation NA NA 2 Nur sing r ela ted Bachelor of Nur sing Support/ Adv anced support (i.e. super vised as a s tuden t) Regis ter ed Nur se 3 NETP NETP NETP Beginner 4 Fir st and sub sequen t RN/PHN positions Orien ta tion t o PHN Short c our ses, Nur sing K no wledg e and Skills; e. g. vaccina tion, Cer vic al Smear t ak er certific at es, e tc. (pr escribing c our ses) 6 Tr ansition RN Pr oficien t RN

RN with prescribing (op

tional) Compe ten t Pr oficien t NZ Certific at

e in Public Health (see Appendix 7).

Le

vel 5 but r

ele

van

t t

o public health nur

sing 5 Adv anced PHN r oles Designa ted r oles (e. g. nur se educ at or , nur se manag er , nur se specialis t) PG Certific at e PG Diploma Mas ter ’s degr ee (pr escribing c our ses) 7 Adv anced PHN r oles Designa ted r oles Expert/ expert with expanded pr actice 6 Nur se Pr actitioner Mas ter ’s tha t mee ts NP r equir emen ts Expert – Nur se Pr actitioner Nur se Pr actitioner 7 Nur se Ac ademic PhD Nur se Ac ademic/ clinician 4 The Nur sing Council of Ne w Z ealand’ s 2010 nur sing w orkf or ce da ta r eport indic at ed ther e w er e only a v er y small number of ‘ enr olled nur

ses’ (ENs) in public health – less than 23. ENs

ar

e not included in this pa

th w ay , but will be c onsider ed within the w orkf or ce r equir ed t o support the RN PHN w orkf or ce. 5 Once initial r egis tr ation is g ained, a nur se main tains r egis tr ation b y mee

ting the Nur

sing Council of Ne w Z ealand’ s Annual Pr actising Certific at e (APC) r equir emen ts. 6 NCNZ is curr en tly c onsulting on c ommunity nur se pr

escribing – once appr

ov ed, this c ould be a use ful model f or PHNs. 7 NCNZ is curr en tly c onsulting on specialis t nur se pr escribing.

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Part 2: Issues and recommendations

This section presents the seven steps of the proposed pathway. It outlines the current situation and

issues, and asks for your comment about the recommendations.

Providing feedback

We invite you to comment as much as you would like on the recommendations for each step. You

can also provide general comments on the framework.

Your feedback will inform the development of the Education Framework and its recommendations.

As well as providing feedback by email or hard copy, we also invite you to share in an online

discussion about the issues. You’ll find links to the online discussion at www.pha.org.nz, along with

other ways to provide feedback.

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Current situation

Students have little information about public health nursing as a career.

Issues

High school students should be exposed at an early stage to information on careers in public health, nursing and public health nursing. This could increase their uptake of science-related subjects, and improve the pool of young people who could progress into nursing. People should understand what their options are before they start a programme of study.

Step 1 – Prior to starting a Bachelor of

Nursing degree

Not promoting career opportunities may mean that opportunities to grow the potential workforce pool for nursing and public health are lost,

reducing graduate nursing numbers and causing future workforce shortages.

Issues and recommendations Issue 1.1

Opportunities to grow the potential workforce pool may be lost if career opportunities are not promoted at an early age to high school students.

Recommendation 1.1

PHN stakeholders actively support initiatives to encourage secondary students and second-chance learners to meet entry requirements for nursing.

Agree / Disagree (please circle) Comment

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Step 2 – Bachelor of Nursing

Current situation

Public health nurses complete a generic Bachelor of Nursing qualification from one of 16 nursing schools in New Zealand.

All schools of nursing are monitored and audited against the Nursing Council New Zealand (NCNZ) nursing education standards, which outline broadly the requirements for curriculum content and clinical experience.

Nursing students complete placements as part of their nursing training.

Issues

The education standards that guide nursing schools are not prescriptive. There is relatively little on population health, with only a reference to “primary health care and community settings” in the “expectations for clinical experience”.8

The curriculum content standard is focused on matching theory with the national registered nurse competencies.

The language used to describe the indicators of “competence” focuses on personal health and nursing care of the individual, with only occasional reference to nurses working with individuals and their whānau and wider communities.9

However course information on four nursing schools’ websites clearly reflects that the concepts of population health, public health, and primary health care, the role of the nurse in community settings or the role of the nurse in population

health are embedded in various courses within their Bachelor of Nursing programmes.10

In addition, related theory from the disciplines of sociology and epidemiology are also evident. The Generic Public Health Competencies are the foundation knowledge and skills expected of all people working in public health. These competencies (shown in Appendix 6) could be used as a guide for the NCNZ education standards. Recognising the unique context of Aotearoa New Zealand, nursing education aims to prepare nurses to understand their Treaty of Waitangi responsibilities to address inequalities between Māori and their fellow New Zealanders.11

Despite the best efforts of the NCNZ, this concept remains unfamiliar and relatively misunderstood. A barrier for students who wish to do a public health placement as part of their training is that many organisations have insufficient capacity to offer placements to students.

Students may decide not to look for public health placements as there are relatively few job opportunities compared to other areas of nursing.

8. Nursing Council of New Zealand. (2010). Education programme standards for the registered nurse scope of practice. Wellington: Nursing Council of New Zealand.

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Issues and recommendations Issue 2.1

The education standards guiding nursing curriculum content and clinical experience do not specifically require the inclusion of concepts of population health and community settings.

Negotiate to increase the required level of knowledge and skills in population health and community settings in the Education Standards, using the GPHCs as a guide and including a ‘reducing inequalities’ focus.

Issue 2.2

The indicators of “competence” in the national registered nurse competencies, appear to focus on personal health and nursing care of the individual.

Negotiate a review of the registered nurse competencies using the GPHCs as a guide to include population health and community settings content.

Issue 2.3

Variable population health and reducing inequalities content in schools of nursing curriculum content.

Encourage or incentivise schools of nursing to review the levels of public health nursing knowledge and skills in the curriculum content in their nursing programmes, using the GPHCs as a guide and including a focus on reducing inequalities.

Issue 2.4

There are few placements available for students who wish to work in population health and community settings.

Facilitate partnerships between schools of nursing and public health nursing employers to offer and promote PHN student placements.

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Step 3 – Nursing Entry to Practice

Programme (NETP)

Current situation

Once graduated, most nurses enter the nursing workforce through the national, DHB- managed NETP programme. NETP provides graduate registered nurses with support and development during their first year of practice. The programme offers a range of placements, including placements in public health nursing.

Issues

The content of the NETP programme has variable amounts of population health knowledge and skills.

Some PHNs believe that the NETP programme does not fully prepare graduates to work

effectively in population health settings. Graduates who want PHN placements as part of the NETP programme have trouble accessing placements,

with the result that many end up working in other nursing areas.

Resource constraints also affect the investment in graduate nurses who wish to be on the PHN career pathway. PHNs often work in small teams, which have limited time and capacity to support newly qualified nurses who wish to be PHNs.

The result is that new nurses who gain placements do not always have a positive experience of the NETP programme.

It is beneficial to expose high school students to careers in public health, nursing and public health nursing. This could potentially increase their uptake of science-related subjects, and improve the pool of young people who could progress into nursing.

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Issues and recommendations Issue 3.1

The content of the PHN NETP programmes delivered at DHB level have variable amounts of population health knowledge and skills.

Work with DHBs to review NETP, and to increase the national consistency of public health

knowledge and skill content, using the GPHCs as a guide.

Are there other existing programmes that you believe might improve NETP?

What suggestions do you have to help nurses have positive NETP programme experiences? Issue 3.2

Graduate nurses seeking PHN placements on the NETP programme have difficulty securing positions.

Recommendation 3.2

Encourage or provide incentives for organisations to invest in newly qualified PHNs and to offer NETP programme placements.

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Step 4 – First and subsequent public health

nursing positions (after NETP) for registered

nurses with or without other nursing

experience

Current situation

While some registered nurses choose public health nursing from the beginning of their nursing career, many more work in a variety of other nursing settings before starting public health nursing practice. Often these registered nurses have gained life experience that deepens their nursing knowledge and skills, which can be invaluable to their public health nursing work.

New PHNs, with or without previous nursing experience, complete in-house orientation

programmes, professional development training to meet Annual Practising Certificate requirements, and other in-service short courses, or graduate/ post-graduate education. While these training opportunities have different degrees of relevance, few are specific to public health.

Issues

New PHNs

Public health nurses are offered local or regional orientation programmes, which may vary in content, length and learning expectations. These programmes often focus on the particular local/ regional requirements of the organisation, role, and community, and may provide limited opportunity for participants to strengthen their population health and public health knowledge and skills.

Registered nurses with other experience

Nurses moving into PHN roles with previous nursing experience often do not receive any orientation to population health concepts and practice. Nor is it usual for them to receive tailored

Nurses doing public health nurse work in primary health care settings

Orientation programmes are usually specific to PHNs, so there are only ad hoc opportunities for registered nurses with a population health approach in primary health care settings to receive any orientation to public health.

Ongoing education after NETP

After orientation to public health nursing, apart from the PDRP programme, ongoing education is not coordinated. Training is often specific to areas of an individual’s work, such as immunisation, child wellness, or housing, and may not even relate to public health.

There is no formal education pathway upon which PHNs can structure their career development, or where nurses doing public health nursing related work can access programmes to meet their knowledge and skill needs.

Continuing quality education is a cost to employers. However, if public health nursing education is not given priority, nurses may not receive the training needed to equip them to be safe and effective practitioners. A lack of investment in nursing development can reduce job satisfaction, and a nurse’s sense of achievement, of being valued and having a vision for one’s

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Issues and recommendations Issue 4.1

PHN orientation programmes are variable in content, length and requirements.

Support the development of nationally consistent standards for orientation programmes (using the GPHCs as a guide), that are suitable for:

• new PHNs

• nurses with other nursing experience • nurses with a population health approach

in primary health care settings.

Issue 4.2

Experienced nurses bring valuable knowledge and skills that are often not recognised.

Develop some form of national “recognition of prior experience” process.

Agree / Disagree (please circle)

How important is this and what do you suggest?

Issue 4.3: There is no formal education pathway for public health nursing career development.

Recommendation 4.3

Develop a national Public Health Nursing Education Framework that provides a pathway for structured public health nursing career development.

Issue 4.4

Resource and other access barriers restrict opportunities for public health nursing career development.

Recommendation 4.4

Identify access issues and barriers to tertiary and non-tertiary training (including in-service) and develop recommendations to improve access.

Agree / Disagree (please circle) Comment and what do you suggest?

12. Generic Competencies for Public Health in Aotearoa New Zealand. Public Health Association of New Zealand for the Ministry of Health; 2007.

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Step 5 – Advanced public health nursing

roles

Current situation

Advanced PHNs (for example, nurse educators, nurse managers, or nurse specialists) improve population outcomes by using an ecological approach to problem-solving.

They add value to the community they serve.13

They have well-developed relationship skills14

and are able to navigate complex health care systems.15_{They manage and co-ordinate care to}

patients, individuals’ families and communities, and provide leadership and education to others using evidence-based approaches.16

Most countries offer post-graduate study for PHNs at this level. A number of tertiary institutions in New Zealand offer post-graduate qualifications ranging from certificates to Master’s degrees. However, these qualifications are not necessarily specific to PHN practice, but may be, for example, specific to primary health care nursing).

One of the aims of a Master’s degree is to empower nurses through building capacity, advanced knowledge, skill and practice.17

The Public Health Leadership Programme offers leadership development opportunities (see Appendix 8) and is a useful option for public health nursing.

Issues

The work of PHNs is both complex and diverse in nature. It requires a specific, yet broad, skill set and a comprehensive knowledge base, so nurses can meet the needs of the populations they serve. To ensure this happens, the advanced

practice/expert PHN must have the opportunity for targeted post-graduate education as part of a career development plan.

The challenges to such opportunities include the availability of relevant post-graduate education, and the costs.

In New Zealand, nurses working in organisations which receive funding from a District Health Board (DHB) can apply to Health Workforce New Zealand (HWNZ) for funding for post-graduate papers and qualifications. HWNZ has clearly defined specifications that must be met in order to qualify for funding. All applications are ranked in order of priority as set by the DHB and incorporate the key priority areas determined by the MOH. This funding is limited, and difficult to access if the application has a low ranking. Many DHBs also link post-graduate funding to the completion of a Professional Development Recognition Portfolio. Internationally, there appear to be a limited numbers of public health nurses studying at Master’s degree and Doctoral level.

The most common contributing factors affecting 13. Swider, S., Levin, P., Cowell, J., Breakwell, S., Holland, P., & Wallinder,J. (2009). Community/public health nursing practice leaders’ views of the doctorate of nursing practice. Public Health Nursing, 26(5), 405-411.

14. Kaiser,K., Barr, K., & Hays, B. (2003). Setting a new course for advanced practice community/public health nursing. Journal of Professional Nursing, 19(4), 189-196.

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career progression of nurses working in public health nursing include:

• a lack of organisational support and incentives from employers to study,18_such

as lack of available leave, no backfill support and difficulty obtaining flexible schedules for people who need to work full-time

• no remuneration for post-graduate achievement

• limited funding for PHNs for post-graduate education; for example, HWNZ funding is limited to clinical study. Access to this opportunity is controlled by DHBs, so a nurse who does not work for a DHB cannot access HWNZ funding for study

• little clear information about what post-graduate study is needed, and what is available.

In the absence of a targeted PHN post-graduate qualification, PHNs are choosing individual papers or courses of study such as primary health care, health promotion and public health leadership.

Advanced public health nurses have well-developed relationship skills. They manage and co-ordinate care to patients, individuals’ families and communities.

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Issues and recommendations Issue 5.1

In the absence of a targeted PHN post-graduate qualification, PHNs are studying other nursing areas such as primary care, mental health, business, Māori studies, health promotion and leadership.

Negotiate with HWNZ and facilitate collaboration between nursing and public health educators to identify opportunities for postgraduate

qualifications that more clearly incorporate public health nursing practice.

Issue 5.2

Access to and employer support for, advanced study for PHNs is unreliable.

Negotiate with HWNZ and work with employers to improve access and support for advanced public health nursing education.

Issue 5.3

Little clear information about what post-graduate study is needed and what is available.

Recommendation 5.3

Complete needs assessment of what public health nursing post graduate qualifications are needed, then develop a guide of what is available.

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Step 6 – Nurse practitioner – PHN

Current situation

The Nursing Council of New Zealand requires completion of a ‘clinical master’s’ among the requirements for designation as a Nurse Practitioner. In 2010, there were only two public health nurse practitioners in New Zealand,19_{one in}

the Waikato and one in Canterbury.20

Issues

Similar to Step 5, the key issues here relate to access to opportunities and employer support to advance to these higher public health nursing practice levels. Applications for funding can be submitted to assist a nurse to progress to nurse practitioner level, but this needs support from the organisation they work for, as it is an expensive

programme including the requirement to have supervision.

New Zealand’s economic climate means organisations have strained resources and investment in advanced education for PHNs may not be a high priority.

Additionally, uncertainty around the employment opportunities for this level of practice may discourage nurses from pursuing NP status.

19. The New Zealand Nursing Workforce. Nursing Council New Zealand, 2010 at page 19. 20. Ibid at page 23.

Issues and recommendations Issue 6.1

There is insufficient promotion and resourcing to encourage nurses to progress to PHN NP level.

Identify the key access issues to becoming a PHN NP and develop recommendations.

Agree / Disagree (please circle) Comment and what do you suggest? Issue 6.2

There are a limited number of positions in New Zealand for this level of practise.

Recommendation 6.2a

Ascertain organisations’ interest in developing PHN NP roles and concurrently promote PHN NP opportunities.

Agree / Disagree (please circle) Comment and what do you suggest?

Recommendation 6.2b

Negotiate with the Ministry of Health and HWNZ to establish a PHN NP pilot (similar to the Diabetes NP pilot) to grow the PHN NP workforce and increase the impact PHNs have on population health outcomes.

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Step 7 – Nurse academic – PHN

Current situation

PHNs who teach at the post-graduate level typically have or are planning to obtain a PhD. There are few PHN nurse academics in New Zealand, as teaching positions are limited and the demand for PHN academics currently appears minimal.

Consequently, people in this workforce are often employed by universities and professional organisations for policy development.

Issues

The key factors impacting on the development of PHN academics include:

• a limited number of PHN academics who can teach/supervise study, which makes it difficult for aspiring nurses to access this level of supervision and leadership

• the lack of a continuous PHN education pathway, so that the pool of people who can reach this level is very small

• a lack of understanding of the benefit of having advanced PHN academics

• the perception that there is no real

recognition for reaching this advanced level. Currently, only a driven, determined and well-resourced person can reach Nurse academic status. Opportunities for PHN leadership across New Zealand fall to just a few.

Issues and recommendations Issue 7.1

A lack of appropriately prepared academics to drive PHN workforce development at the highest academic and political levels in New Zealand.

Provide national scholarships for PHNs to access education opportunities that lead to advanced education levels.

Issue 7.2

A lack of ongoing education pathways to lead people to the nurse academic stage.

Promote pathways to PHN academic level and the

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Where to from here?

Much needs to be done to achieve the

ten-year vision for public health nursing workforce development.

The success of public health nursing growth and development in New Zealand requires careful planning and prioritisation, driving leadership and widespread commitment. A contemporary, well-positioned public health nursing workforce needs investment through a national infrastructure and from the organisations where nurses work. To make this happen two things will be needed:

1. Ownership of this work

Because workforce development issues for PHNs will continue, it is critical to plan how these issues will be addressed once the Education Framework is developed, and identify who will take responsibility for the work arising from the Education Framework.

2. Connections with other public health disciplines

The project team and the advisory group will be exploring how this work connects with the developing multidisciplinary approach to public health initiative, led by a group of sector leaders with support from the Public Health Association.

Thanks to the public health nursing sector, and everyone interested in the development of public health nursing, for your time and contributions to this discussion document.

We will let you know about future opportunities to influence directions for this work.

Public health work focuses on improving the overall health of populations, such as children, through interventions such as immunisation, health screening checks, or safer housing.

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Appendix 1: Te Uru Kahikatea objectives

relevant to public health nursing

Te Uru Kahikatea (TUK)21_{is the national strategy to}

grow and develop the public health workforce in Aotearoa New Zealand.

TUK Goal 1: Develop an effective and sustainable public health workforce

Public Health Sector Professional Development

Objective 4:

Build infrastructure for public health professional development.

Action 4.2

Establish (where they do not already exist) professional development mechanisms or key public health workforce groups to lead professional development, develop competencies and standards, and achieve external recognition; in particular:

• work with leaders/stakeholders for public health nurses, community health workers and other public health disciplines to identify ways of supporting the professional needs of the respective workforce groups.

Te Uru Kahikatea is the national strategy to grow and develop the public health workforce in Aotearoa New Zealand.

21. Te Uru Kahikatea: Public Health Workforce Development Strategy, 2007-2016. Ministry of Health, Wellington, 2004

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Appendix 2: Individuals involved in this

project

Project sponsorship

Public Health Workforce Development, National Health Board, Ministry of Health Health Workforce New Zealand, National Health Board, Ministry of Health

Working group

Jenny Hugtenburg – Project Manager, Regional Public Health, Wellington.

Viv Head – Workforce Development Consultant, Head Strategic Limited

Rhonda Mikoz – PHN, PHN Professional In-Service Development Coordinator, Canterbury DHB Jan Waldock – NZ College of Primary Health Care Nurses

Lizzie Farrell – Clinical Nurse Manager and PHN, Kidz First, Counties Manukau DHB Paul Watson – Senior Advisor, Nursing, Ministry of Health

Keriata Stuart – Strategic Advisor, Māori Public Health, Public Health Association Evelyn Hikuroa – Nurse Lecturer, Manukau Institute of Technology

Advisory group

Diana Lennon – Professor Medical and Clinical, Department of Paediatrics, Auckland University Grace Wong – Senior Lecturer, Auckland University of Technology

Marjorie Schaffer – Professor of Nursing, Bethel University, Minnesota Phil Shoemack – Medical Officer of Health, Toi Te Ora Public Health Service

Rhonda Mikos – PHN, PHN Professional In-service Development Coordinator, Canterbury DHB Taima Campbell – Director, Hauraki health Consulting

Amy Hamerton – Senior Policy Advisor, Health Workforce New Zealand

Maureen Kelly – Education Manager, Nursing Council of New Zealand

Vicki Noble – Director of Nursing, Primary Health Care, Capital and Coast DHB Denise Kivell – Director of Nursing, Counties Manukau DHB

Lizzie Farrell – Clinical Nurse Manager and PHN, Kidz First, Counties Manukau DHB Sarah Little – Director of Nursing, Auckland DHB

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Appendix 3: Public health nursing

demographics

In 2010, the Nursing Council New Zealand

completed a survey of the total nursing workforce in New Zealand. They received a 95-100 percent response rate to the survey. In interpreting the survey, please note it allowed for multiple employment areas (up to two) and multiple practice areas (up to two).

Some PHNs may have identified themselves in these other categories rather than the broad ‘public health’ category.

Numbers in the workforce in 2010

• 789 nurses identified as PHNs in their application for their annual practicing certificate

• 266 PHNs work 1.0 FTE or more • 268 PHNs work 0.9 FTE or less

• The remainder work in more than one employment setting, so are likely to be part time in public health.

Demographic characteristics

• 763 female (97%); 26 male (3%) • 516 > 45 years of age (65%) • 274 < 45 years of age (35%) • 514 identify as NZ European/Pākehā (65%) • 76 identify as NZ Māori (9%) • 36 identify as Pasifika (5%)

• 287 identify as other nationalities or not stated (36%).

Country of registration

• 590 (77%) were first registered in New Zealand

• 117 (15%) were first registered in Australia, the UK or North America

• 57 (7%) were first registered in other countries.

Post-registration qualifications

• 481 (63%) PHNs report holding one or more post-registration qualifications

• This compares to 58% of registered nurses overall.

Areas of professional specialisation

• 2 Nurse Practitioners – Public Health • 1 Waikato

• 1 Canterbury.

Who employs public health nurses?

• Majority of PHNs are employed by DHBs • Public Health Units

• Departments such as child health, family health.

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Appendix 4: History of public health nursing

by Elizabeth Farrell, 2013

Introduction

In order to understand the scope of public health nursing better, it is useful to trace the historical development of public health nursing from the late nineteenth century to the present day. This information is included to assist the reader to gain insight to the unique contribution PHNs have made to improve the health of communities both locally and internationally.

Public health nursing in the past

Public health nursing began as a health service to ‘poor women’ and their families in Britain and America in the mid-nineteenth century. It arose in response to the poverty, unemployment and high infant mortality that became evident to local authorities within communities.

In the early nineteenth century in Britain, Florence Nightingale introduced a model of nursing

education, which influenced the development of nursing as a profession, firstly in Britain and then the United States of America (USA) and later Australia and New Zealand (Francis, 2001). The introduction of the ‘health visitor’ in England was an attempt to provide poor families with nursing care as well as advice on preventative health measures such as “domestic hygiene and child nurturing” (Francis, p.171).

Not surprisingly, Florence Nightingale included epidemiology in the curriculum for nurses training at her schools of nursing thus supporting an early model of health care that was based on the health needs of the community (Francis). This first attempt to define population health became part of the foundation of public health policy in Britain, USA and ultimately in New Zealand.

nursing, established the Henry Street Settlement in New York City. By 1905, a public health nursing service was providing a home visiting service to the settlement homes in the poorer parts of New York City.

These PHNs were trained in public health as well as general nursing and were able to use these newly emerging strategies to prevent infectious diseases such as tuberculosis, typhoid and the common childhood illnesses diphtheria and whooping cough (Buhler-Wilkerson, 1985). In 1902, Wald introduced PHNs to schools in New York through her concerns for the number of children absent from school.

“Many children were absent for lack of shoes or clothing, because of

malnourishment or because of serving their families as babysitters” (Hawkens, Hayes & Corliss 1994, cited in Stanhope & Lancaster, 2000 p.27).

Interestingly, there was concern at the number of school children who suffered from common conditions such as pediculosis, ringworm, and discharging ears, conditions that remain common problems for children living in New Zealand today. New Zealand became the first country to

introduce a statute to register and regulate nurses and this was achieved by the passing of the

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Women and Children (now known as The Royal New Zealand Plunket Society), and the passing of the Child Welfare Act 1907 (Wood, 2001). In 1909, the Backblocks Nursing Service and the Native Health Nursing Service provided nursing care to families in the very isolated newly settled areas of New Zealand (Lambie, 1951). By 1927 the school health service was well organised with a medical officer having overall responsibility for regional and geographical areas in New Zealand. Dr Eleanor McLaglan commented at the time:

“The nurse’s job was to visit homes to supervise the treatment of minor conditions and to advise where to take the children for more complicated treatments, often making appointments and personally escorting them there. Ideally each nurse would stay some time in the district and get to know the children by sight” (Tennant cited in Bryder, 1991, p.137).

Thus, nurses were central to these early attempts to provide preventative health strategies as well as treatment of diseases.

McLaglan also described the difficult living conditions where the nurses found their clients and spoke of “slums and wretched courts behind the respectable houses were the hunting grounds of excellent nurses who were skilled in tracking unhappy and neglected children to their homes” (Bryder, 1991, p.137).

Many PHNs of today would relate to this statement as being very similar to their current nursing practice. Tracking highly mobile children to

follow up unaddressed health concerns and often more serious child protection situations is routine public health nursing practice today.

Public health nursing in the present

Public health has been described as “the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society” (Cowley, 1998, p.29).

Public health nursing practice has been described as “population focused community orientated nursing practice that emphasises the prevention of diseases and disability and takes place through assessment, policy development and assurance activities of nurses working in partnership with communities and or groups” (Williams cited in Stanhope & Lancaster, 200o, p.15). Just as the early PHNs responded to the needs of the community so do present day PHNs.

The client base can vary from one small child to a whole school community or even the entire country. One example was H1N1 Influenza epidemic in 2009 in New Zealand, when PHNs were involved in border control and contact tracing in an effort to prevent wide spread disease.

The effectiveness of public health

nursing

The effectiveness of public health nursing is well documented in the literature. Zerwekh (1991) discusses the invisibility of the profession but highlights the effectiveness of PHNs in many neighbourhoods in America, while from a New

In the early nineteenth century Florence Nightingale (left) introduced a model of nursing education, which influenced nursing as a profession. In 1902, Lilllian Wald (right) introduced public health nursing to schools in New York.

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Zealand perspective Gallagher (1999) likens the practice to strands or threads of a tapestry – all the threads make up the tapestry but in isolation mean little. It is the intimate understanding of the health needs of the community and the development of relationships with members of the community – whether with a family, a school, or a smaller community – that is unique to public health nursing.

In New Zealand, PHNs’ scope of practice is determined by contractual obligations with the Ministry of Health (MOH), through local District Health Boards. Under Section 125 of the 1956 Health Act, PHNs have a statutory right to assess, and if necessary examine, a child at school if there are health, care and protection concerns. Child protection issues such as neglect, emotional, physical and sexual abuse are routinely assessed by PHNs along with other health concerns such as skin infections, hearing impairment and ear disease.

Advice and information is given to individuals or groups about the prevention of infectious disease such as whooping cough as well as vaccine preventable diseases. This is also is supported by school based vaccination programmes.

Environmental and social issues

affecting public health nursing

practice

Compounding the work of the PHN is the pervading poverty and social exclusion that often result from unemployment, lack of work skills and associated poverty. Family violence

and substance abuse are often part of the fabric of these communities, and while the impact on health is often not always noticed by other health professionals working in hospitals and clinics, it is inescapable to the PHN who brings the services to the door through home visiting.

A current public health nursing

initiative

In most public health nursing services in New Zealand, PHNs work in a defined geographical area and become experts in their knowledge of the community infrastructure and support agencies available in that community. PHNs, because they have direct contact with individuals and families, are also in an ideal position to lead health promotion initiatives at the grassroots. They can work with a family or a school group to develop health promotion initiatives in response to identified local health needs.

A current example is the MOH 2012 rheumatic fever prevention funding to establish sore throat clinics in schools where there is a high incidence of this disease. This multidisciplinary approach reflects the collaborative partnerships used by PHNs to include people affected by a given health concern and is an example of a population approach to addressing the health concern. More recently models of PHN practice have been developed especially in the United States of America which have been utilised in part by some PHN managers/leaders into the New Zealand context.

References

Bryder, L. (Ed.). (1991). A healthy country. Essays on the social history of medicine in New Zealand. Wellington: Bridget Williams Books.

Buhler-Wilkerson, K. (1985). Public Health Nursing: In sickness or in health? American Journal of Public

Health, 75(10), 1155-1161.

Francis, K. (2001). Service to the poor: The foundations of community nursing in England, Ireland and New South Wales. International Journal of Nursing Practice, 7, 169-176.

Gallagher, L. (1999). Expert public health nursing practice: A complex tapestry. Nursing Praxis in New Zealand, 14(3), 16-27..

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Appendix 5: Short-, medium- and long-term

visions for PHN workforce development

Year 1: Adoption of an education/training framework that identifies the workforce development requirements of PHNs, to enable PHNs to make an increasingly positive contribution to health outcomes in New Zealand Aotearoa, achieved when:

• communication and consultation with stakeholders is effective

• PHN demographics are known and taken into account

• entry/orientation programmes for new PHNs are known and an approach to making them more consistent is agreed upon

• a literature review on PHN education and career frameworks internationally informs the approaches taken in Aotearoa New Zealand

• education and training gaps are identified and a plan is in place to address them • PHN issues are considered integral to relevant projects, e.g. multidisciplinary approaches to public health; National Certificate in Public Health

• the education/training framework for PHNs is supported by PHNs, PHN leaders, the Ministry, HWNZ, nursing and public health education providers, and DHB Directors of Nursing

• a plan is in place for further PHN workforce data collection

• an owner/champion/s for the next 2-3 years is agreed (i.e. a home for the implementation of what this project develops, ensuring it is embedded in future structures).

Year 2 – 5: Public health nurses work at the top of their scope of practice, achieved when:

• education, training and professional development opportunities support extension of the PHN scope of practice • recognised mechanisms are in place to

enable PHN leaders to interact regularly with each other

• barriers to accessing the PHN education pathway as identified through the

implementation at year one are minimised. Year 6 – 10: Their communities and colleagues recognise public health nurses as leaders, achieved when:

• highly skilled PHNs work alongside public health colleagues who have a recognised public health qualification

• PHNs lead work streams

• PHN specialist registration is in place • PHN career and educational pathways are

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Appendix 6: Generic Public Health

Competencies

The Generic Public Health Competencies are the minimum baseline set of competencies that are common to all public health roles and disciplines across the health sector, and that are necessary for the delivery of essential public health services. They are a minimum in all areas of what all public health practitioners are expected to be capable of doing in order to work effectively in the field. The competencies provide a ’whole of sector’ view of the workforce development required to meet the public health aims of improving the overall health status of the population and reducing health inequalities. They are intended for use by practitioners, managers, policy makers and analysts, educators and trainers, and funders and planners.

The competencies also form the basis of the Certificate of Public Health, discussed in the next appendix.

1. Public health knowledge

• Health systems

• Public health science

• Policy, legislation, and regulation • Research and evaluation

• Community health development.

2. Public health practice

• Te Tiriti o Waitangi

• Working across and understanding cultures • Communication

• Leadership, teamwork, and professional liaison

• Advocacy

• Professional development and self-management

• Planning and administration.

For more information see Generic Competencies for Public Health in Aotearoa New Zealand, written by the Public Health Association of New Zealand in association with the Health Promotion Forum of New Zealand, Māori community health workers, New Zealand Institute of Environmental Health, Public Health Nurses Section of New Zealand Nurses Organisation. 2007.

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Appendix 7: New Zealand Certificate in

Public Health

Current situation

Beginning in 2014, the level 5 (undergraduate) national New Zealand Certificate in Public Health is expected to be delivered by at least one tertiary education provider. The certificate is based on the Generic Public Health Competencies (GPHCs) and is the baseline standard of public health knowledge and skills for all people working in public health environments. It is intended to be both a first tertiary qualification and suitable for those who already hold degrees.

The delivery modes proposed for the one-year PH Certificate are block courses and online learning. It is hoped this delivery mode will minimise time away from work for students. Prior learning and current competencies will be recognised, enabling some students to complete the certificate more quickly.

Discussion and summary of issues

While the GPHCs and the Certificate in Public Health do not have a specific nursing focus, both enable nurses to gain a foundation of generic public health knowledge and skills relevant for every PHN role.

Given that the Certificate in Public Health is an undergraduate level 5 course, it may or may not be the preferred study choice for PHNs. What is important is that there are courses of study available and different qualification levels for those who wish to strengthen their public health knowledge. The New Zealand Certificate in Public Health offers access at lower levels of the qualification spectrum.

Additionally, it is also important that all foundation and orientation programmes for PHNs include a solid foundation of public health knowledge and skills. The GPHCs could provide this broad based public health foundation content. Using the GPHCs to inform the content of existing and new PHN education and development courses could assist PHNs to be equipped for practice in public health environments.

PHNs are registered nurses who use their nursing expertise alongside their wider knowledge of communities, to promote health and wellbeing.

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Appendix 8: Public Health Leadership

Programme (PHLP)

What is the PHLP?

The PHLP is a residential leadership programme designed specifically for public health leaders in New Zealand. The programme is funded by the Ministry of Health and run by Quigley and Watts, and Catapult. The PHLP has been developed following extensive consultation with the sector. It builds competencies identified as important for leaders in public health.

The PHLP allows participants to discover their leadership potential and equip them with practical and tested leadership tools and resources. The programme will generate immediate and lasting benefits for participants, those they lead, and for public health.

The PHLP has a six-day residential leadership component delivered as three two-day sessions. Currently, there are two programmes per year.

Who is it for?

The PHLP is for leaders wanting to inspire, refresh and create a powerful foundation for their leadership development. It is not designed to teach public health. Participants are expected to have a good knowledge of public health

principles including an understanding of the social determinants of health, inequalities in health, how culture influences health, and the significance of the Treaty of Waitangi in health.

Why choose the PHLP?

The PHLP was designed to meet the leadership challenges facing public health. It develops leadership competencies identified as essential for public health leaders. The programme is firmly grounded within the reality of public health. Case studies drawn from public health and practical sessions will allow for application back to work. The PHLP explores what is at the source of powerful leadership. Participants gain

transformational insights into themselves and the nature of leadership.

The PHLP is created specifically for New Zealand public health leaders. The case studies and examples used are based on the work Quigley and Watts and Catapult have undertaken with hundreds of New Zealand leaders and organisations. This means the content will be directly applicable to participants’ work.

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Funded by: The Ministry of Health

Project managed and written by the Public Health Nursing Education Framework Working Group, the Public Health Association of New Zealand and Head Strategic Limited